Healthcare Provider Details

I. General information

NPI: 1770865883
Provider Name (Legal Business Name): MARIAN SANTANDREU MIRABAL PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAN SANTANDREU

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 07/29/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 JEFFERSON STREET
HARTFORD CT
06106
US

IV. Provider business mailing address

125 LIBERTY ST STE 102
SPRINGFIELD MA
01103-1109
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-0200
  • Fax:
Mailing address:
  • Phone: 413-200-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9906
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4020
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: